Sexuality and Mental Health Professor Dinesh Bhugra dineshbhugra

Sexuality and Mental Health Professor Dinesh Bhugra @dineshbhugra

Definitions • Sexual Variation-lesbian, gay, bisexual and transgender • What does it mean? • Variation-statistical? Deviance? Deviation? • How is it defined and who defines it?

Definitions • Gay-colloquial and affirmative term for homosexual; also political whereas some women may prefer to use the term lesbian • Bisexual: erotically attracted to both male and females-a sexual identity • Transgender-someone whose gender identity and sex are discordant with each other relative to social norms

Definitions • LGBTQ/GSM/DSG/QUILTBAG: Lesbian, gay, bisexual, transgender and queer/GSM: Gender and sexual minorities/DSG: Diverse gender and sexualities/Quiltbag: Queer (questioning), undecided, intersex, lesbian, bisexual, asexual (allied) and gay • Sexual Fluidity: Fluctuating mix of options available • Questioning: Exploring one’s sexual orientations

Definitions • Intersex: A person with sexual anatomy that doesn’t fit within the labels of female or male (e. g. 47, XXY phenotypes, uterus and penis • Pansexual: A person who experiences sexual, romantic, physical or spiritual attractions for members of all gender identities and expressions • Queer: An umbrella term to describe individuals who do not identify as straight (heterosexual) • Cisgender and Transgender: A person whose gender identity, gender expression and biological sex all align is cisgender whereas transgender is a blanket term for all those who are not cisgender

Definitions • Homosexual- same sex attraction-historical use seen as negative and offensive • Homo-ignorance • Homophobia-irrational fear and hatred heterosexual people may feel towards homosexual individuals and may be internal or external • Queer-initially abusive now descriptive academic

Definitions • Sexual Minority-another term for LGBT but some see transgender individuals as gender minority • Sexual orientation-whether someone is attracted to same-sex partners, other sexpartners, both or neither • Gender identity-self-identification as male or female or other gender

Society and Variation • Bullough (1973) divides societies into sexpositive and sex -negative depending upon their attitudes to sexual activity and whether sex is seen as essential for pleasure or for procreative purposes only

Other factors in variation • Attitudes to masculinity • Gender roles • Attitudes towards same sex experiences e. g. Sambia • Culturally accepted and expected roles e. g. hijras in India • Variation-historical changes?

Prevalence rates of sexual minorities • Number of non-heterosexual individuals depends upon which of these sexual domains are assessed and prevalence rates vary between 1 -16% (Savin-Williams et al 2012) • By age 28, 2% men and 4% women identify their sexual orientation as gay, lesbian or bisexual---> 6% of men and 20% women claimed that they were not exclusively heterosexual

Kinsey surveys • • Largely veterans after the Second World War 6 - point scale from exclusively heterosexual Largely heterosexual Equally Largely homosexual Exclusively homosexual A score of 3 reflected an equal degree of attraction to, or equal sexual experience with, both males and females. Wide variety (Klein et al. , 1985),

Sexuality • • Sexual feelings Gender identity Bodily differences Reproductive capacities Sexual needs Sexual desires Sexual fantasies Erotic practices Weeks (2010)

Explanations • Perceived Burdensome • Thwarted belonging • Joiner (1995) suggests that both these feelings may contribute to a sense of despondency and seeking a way out which may lead to suicidal ideation and acts

Lesbian experiences • Similarities and differences between homosexual men and lesbians in terms of coming out and politicisation • Lesbians have similar stages of coming out and may have similar problems • Lesbians may arouse more anger and negative feelings ? Seen as threat to masculinity

Bisexuality • Bisexuality refers to the phenomenon of sexual interest in both sexes, as implied by the prefix ‘bi’ which means two, or dual (cf. Godenson & Anderson, 1987). • It consists of a mingling of sexual feelings, behaviour and romantic inclinations that does not easily gel with society’s categories of typical sexuality (Weinberg et al. , 1994). • Dual attraction, equal or otherwise?

Minority Stress • Meyer (1995) describes that individuals with alternate sexuality experience the burden of a minority status in addition to the routine stressors experienced by them on a day to day basis. Growing up, such individuals come to realize that they are part of a group that is less valued by the society and is vulnerable to prejudice and discrimination.

Minority Stress • These negative experiences get internalized leading to future negative expectations from one’s own identity and sexuality often increasing one’s vulnerabilities and risks. • Individuals with alternate sexuality navigate their lives differently and the associated stresses increase their likelihood of developing mental health difficulties.

Minority Stress • Hatzenbuehler et al (2009) investigated the modifying effect of state-level policies on the association between mental health and sexuality in a survey of 34, 653 participants of whom 577 were identified as LGBT individuals. • Psychiatric co-morbidity among LGBT individuals was 3. 5 times higher.

Minority Stress • The states with no policies of protection to LGBT individuals showed higher rates • Any mood disorder to be twice (20. 4%) in comparison with heterosexual sample (10. 2%); • Anxiety disorder (30. 1% in comparison with 16. 1%) • Substance abuse was 40. 8% cf 20. 9% but alcohol use was 2. 5 times and drug disorders x 5 more common.

Minority Stress • Hatzenbuehler et al. (2012) noted, after the legalization of same-sex marriage, sexual minority men had a significant decrease in mental health care visits as well as a reduction in hospital visits related to physical ill-health, in comparison with data 12 months prior to legalization. • Clear role of social factors

Minority Stress • USA (n = 11, 949 LGBT: n = 352, 343 non-LGBT respondents) • Higher levels of local approval of same-sex marriage lowered the probability that LGBT (and non-LGBT) individuals reported smoking and fair/poor self-rated health; further, LGBT disparities in smoking were lower in communities where residents were most likely to support same-sex marriage. Hatzenbuehler et al. (2017)

Minority Stress • Mc. Nair et al. , (2005) from Australia showed that 38% of same-sex attracted female respondents between the ages of 22 -27 years had experienced depression compared to only 19% of heterosexual female respondents and also experienced higher levels of anxiety (17. 1% vs 7. 9%). This was found after adjustments were done for age, region of residence and education.

Minority Stress • Sexually variant women i. e. women who identified self as bisexual or lesbian, were more likely to have tried to harm or kill themselves in the previous 6 months. Higher rates of self-harm and suicidal thoughts have been linked to violence and harassment in same-sex attracted individuals (Hillier et al. , 2005) confirming findings from other parts of the world.

Suicidal Behaviours • Suicidal thoughts- 48% (Hammelman, 1993) -76% (Rotheram-Borus et al, 1994) • Attempted suicide: 29% (Hammelman, 1993) - 42% (Hershberger & D’Augelli, 1995). • Adolescent girls with same sex attraction- more frequent SI & SA (Russell & Joyner, 2001). • Same-sex orientation youths more than 2 times more likely than their same-sex peers to attempt suicide (Russell & Joyner, 2001).

Suicidal Behaviours • Both population based and twin studies from different countries have found that LGB people are three to six times more likely to attempt suicide than heterosexual people (Herrell et al. , 1999).

Prevalence Deliberate self-harm higher in lesbian girls Suicidal ideation elevated in LGBT groups Depression rates higher twice than controls Anxiety rates twice or more Alcohol misuse rates also elevated more in women • Drug misuse rates higher also in women • • •

Culture "learned, shared and transmitted values, beliefs, norms and life ways of a particular group that guides their thinking, decisions, and actions in patterned ways" Leininger (1991)

Culture • • Is dynamic Changes subtly over time Can change acutely Culture is integrated People acquire culture without necessarily being conscious Culture ensures generational continuity Influences cognitive and social development Multiple cultural identities, may be conflicting

Culture • Cultures have five dimensions: Individualism – collectivism; feminine-masculine; distance from centre of power; uncertainty avoidance; and long-term –short-term orientation Hofstede ( 1980/2001) • These observations come from company structures and cultures • Micro-identities: especially relevant to sexual variation

Issues in sexual behaviour • Sexual behaviour-What, who and how? • Sexual fantasy-what and who? • Sexual availability-what and who?

Legal Systems • 71 countries around the globe are using laws which make same-sex behaviour illegal • That rates of psychiatric disorders drop following changes in law and bringing in equality has been shown consistently

Attitudes • • • Stigma Self-stigma Coming out? Therapists attitudes Societal attitudes

Doctors’ attitudes • Related to age, ethnicity, experience and speciality • Psychiatrists’ attitudes most positive • Educational and socio-economic status? • Older doctors more negative- they also see homosexuality as life style choice, fear of heterosexuality, danger to children • Young female doctors more positive and comfortable Bhugra (1997)

Medical Students’ attitudes • 428 medical students (50% male) • Although the majority held positive views, a significant proportion (10 -15%) held very negative views. • When religious beliefs were important in moulding their views, there was a significant correlation (p, 0. 001) with more negative attitudes towards male homosexuality and bisexuality. Parker & Bhugra (2000)

Medical Students’ attitudes • Older students had more positive attitudes • Female students had more positive attitudes • Stigma: Male homosexuals are (in) capable of forming stable relationships; are neurotic; would prefer to be female and should not be employed in schools and are a danger to children Parker & Bhugra (2000)

Medical Students’ attitudes • From India, Kar et al (2018) reported that of 270 students who responded 22 % felt that homosexuals were neurotic, 28% thought homosexuals were promiscuous • 8% thought homosexuals posed danger to children 8. 2% (22/270) • 16% (43/270) saw homosexuality as an illness.

Medical Students’ attitudes • From Paraguay, Torales et al (2018), 77 medical students given a questionnaire. • 28. 6% of the participants obtained a negative score to tolerating homosexuality • More positive scores if they had at least one gay friend. • Which comes first? Positive attitudes or friendships?

Coming out • Defined as commonly shared cultural experience defining a modern LGB identity • Means telling another person that one is gay, bisexual or lesbian • Difference between gay and homosexual

Coming out • Herdt and Boxer (1993) define coming out as a ritual or process of passage that requires an LGB person to unlearn : • the principles of natural and essentialist heterosexuality, • Stereotype of homosexuality and • Learn the ways of LGB culture they are entering

Impact of coming out • Politicisation of the individual? • In couples different stages of coming out • Stages in coming out-to self, to others generally friends before family and then colleagues and others • Process accompanied by anxiety or relief and each response will then decide what needs to be done

Specific issues • Coming out later in life • Coming out in ethnic and cultural minorities • Bi-phobia and homophobia will affect coming out processes • Role of the clinician • Legal issues

Coming out • • Feeling different Same sex attraction Questioning assumed heterosexuality Same sex behaviour Self-identification Disclosure Romantic relationships Self-acceptance and synthesis

Coming out • Becoming aware of sexual feelings can be confusing. • Suicidal behavior is more common when they have become aware of their sexual feelings, but before they have talked about it with others. • Any negative experiences with disclosing sexual identity may well affect a person’s well being & opportunities for future success.

Coming out in Asian gay men • Families and religion are very important factors in deciding when and who to come out to • Muslims had more difficulties • Friends first then sisters and then rest of the family • Dissonance • Gay identity may differ Bhugra (1997 a)

Coming out in Asian gay men • Cultural conflict— descendants of migrants face culture conflict within the families; families feel let down; finding a niche in gay community; reconciling ethnic and sexual identities • Double minority status • Asian or Black identity racism versus homophobia both affecting self-esteem

Coming out in India • In a small sample of 28 gay men belonging to a gay group in Mumbai - only 17 of the respondents were ‘out’ to others apart from the members of gay groups. • Female friends (7), cousins (3), siblings (2), parents (l), neighbours (2) and doctors (2). In fifteen subjects, parents did not know and 12 were clear that they did not want their parents to know. Of those 13 where parents knew, in seven subjects, their parents found out accidentally through their neighbours.

Coping with homosexuality • Eighteen (65%) subjects acknowledged that they would make positive attempts at hiding their sexual orientation • Getting female friends to ring them at work, • Being overly friendly with females, • Controlling their demeanour acting macho • Talking excessively about females • laughing away questions about marital status, and pretending to be involved with many girls, and being ‘dishonest’ Bhugra (1997 b)

Self-stigma • When asked if they would take a pill to make them completely and permanently heterosexual, eight subjects said that they would as it would linked with making life simpler, avoiding a horrible life and society’s discriminations, covering up, having family and children, being unhappy, not having a regular partner and being normal.

Social pressures • There were some who, while not regretting being homosexual, were dissatisfied with the state of affairs which was linked with society’s attitudes, not having regular partners, not being able to show affection openly and the parental pressure to get married.

Family response • One subject was thrown out of his brother’s house and the family broke all links with him because they thought this was a Western disease and he was letting the family down. • Influence of culture, which often did not draw a distinction between being gay and being a eunuch. Bhugra (1997 b)

Coming Out • Efficacy expectations: performance accomplishments, vicarious experiences, verbal persuasion and emotional arousal and are all affected by exposure, modelling, performance etc • Self-efficacy plays a role here. . . Bandura (1977)

Lesbian experiences • Similarities and differences between homosexual men and lesbians in terms of coming out and politicisation • Lesbians have similar stages of coming out and may have similar problems • Lesbians may arouse more anger and negative feelings ? Seen as threat to masculinity

Hijras in India • Hijras are transgender individuals who may sometimes be confused with the concept of eunuch in the West. Specific religious and socio-cultural values and roles. They are described in ancient Indian texts of Hindu, Buddhist or Jain origins as the third sex- variously referred to as kliba, pandaka, tritiyaprakriti, or napumsaka (see Reddy, 2005 ).

Hijra Identity • Hijra identity has been often viewed as lying closest to the Western transsexual identity: born in the wrong body with the wrong sex. Some hijras claim of not belonging to either sexes and say that they belong to the third sex: the true hijras (Nanda, 1999; Reddy, 2005; Revathi, 2005).

Hijra Identity • This is a heterogeneous group with a variety of identities that are accommodated within the hijra clan, such as effeminate gay men called zenanas, transsexual women (pre/post-castration), transvestites and true hermaphrodites (rare). Thus the hijra role can be seen to accommodate different gender identities in a culturally accepted but marginalized way • Over the years, this has evolved in to various subcultures of its own existing in the wider heteronormative Indian society.

Bisexuality • Bisexuality refers to the phenomenon of sexual interest in both sexes, as implied by the prefix ‘bi’ which means two, or dual (cf. Godenson & Anderson, 1987). • It consists of a mingling of sexual feelings, behaviour and romantic inclinations that does not easily gel with society’s categories of typical sexuality (Weinberg et al. , 1994). • Dual attraction, equal or otherwise?

Bisexuality • While heterosexuality and homosexuality are described as the attraction towards the opposite or the same gender, bisexuality could be considered to be either a sum of or intermediate between the two polarised sexualities, or even a discrete entity • Focus group findings-emotional closeness with one group Bhugra & De Silva (1998)

Sexual Identity • Self-ascription in spite of its problems happens to be one of the most important parts of an individual’s identity. • Most bisexual individuals are self-identified, in that they see themselves in this position. Not many of them will be ‘out’. • There also some who have bisexual interests, or even experiences, but do not see themselves as such • Role of labelling and micro-identities

Bisexuality • Self-reported sexual arousal (to both male and female sexual stimuli) differed from genital arousal patterns which were more strongly associated with one sex or the other (most of the time the pattern being similar to gay men).

Bisexuality • In general, bisexual men did not have strong genital arousal to both male and female sexual stimuli but most bisexual men appeared homosexual with respect to genital arousal though not all • In contrast, their subjective sexual arousal did conform to a bisexual pattern Rieger et al (2005)

Gender Identity disorders • One in sixty thousand people • Rarely encountered by GPs • Not often encountered by a Community Mental Health team • Competent treatment is shaped by the guidelines of the World Professional Association for Transgender Health

Differential diagnosis • A quite small proportion of patients of either sex seem to have had a sense of being of the physically opposite sex from their earliest years. • A hugely greater number of patients make this claim, only for interviews with parents to subsequently refute it or cause it to be modified to a history of childhood cross dressing – which does not amount to a GID.

Case: Cultural factors • • Patient from UAE Requests change of role from female to male Based on sexual desire for other women Assumed must imply a male identity History of childhood tomboyishness Sent to London Friend Returns six months later, keen to remain in UK, with partner and without desire to change gender role

Case: Cultural factors • Young Italian male. • Saw the macho elements of culture as repressive. • Experimented with cross-dressing when he was in his early teens. • First sexual experiences were with other males. • Began to wonder whether it would be better to have the operation to be a woman. • Encouraged by some of the men with whom he was having sex.

Case: Cultural factors • Family found about the sexual contacts. Disgusted. Moves, in order to prostitute himself. Found the lifestyle violent. • Transsexual friend encouraged him to take hormones. He grew breasts. • Forms the idea that if he were fully female he would be happier. • Moves to London. Becomes like any other gay man • Fleeting doubts but says he would have gone further when it was more easily possible. Hides his breasts and is no longer pleased but instead is annoyed when sexual partners (men) pay attention to them

Personality/social factors • Sixty-seven year old male • Requests change of gender role on basis of having failed as a man • History reveals thirty-years non-consummation based on ignorance and religiously motivated sexual inhibition • Considerable marital strain • Basic education (much delayed) seemed to help

Third Sex • Patients viewing themselves as neither male nor female-can be very culturally influenced • Wish not to be identifiable as either sex • Very rare • Mostly biologically female • Request removal of all secondary sexual characteristics • Overlap with schizoid PD

Issues in management • • • Therapists attitudes? Therapists orientation and matching? Legal issues Discrimination Families responses LGBT parenting issues

Issues in management • • • Should therapist self-disclose? Identity problems Overlap of dimensions Multi-faceted nature of sexual orientation Labels may be over-simplifying Religious/spiritual problems and factors

Conclusions • • Research data are limited across cultures Cultural values Therapists’ prejudices Ways forward in engagements